Failure to thrive

3.7 Failure to thrive



Daryl Efron


Satisfactory growth is a key marker of good health in infancy and early childhood, and so the failure of a child to grow as expected is naturally a cause for concern for parents and health professionals. Failure to thrive (FTT) can result from a broad range of organic and environmental factors, with a combination of influences usually operating. The family often feel confused, worried and guilty, so evaluation needs to be conducted sensitively.




image Practical points




• Failure to thrive is commonly due to a combination of factors, with psychosocial issues often prominent.


• Chronic illness in any system can result in failure to thrive.


• Investigations are unlikely to reveal a cause that was not apparent from a thorough history and examination.


• A multidisciplinary approach is necessary, with input from paediatricians, maternal and child health nurses, dietitians, speech pathologists and sometimes mental health professionals.


• Admission to hospital is required in severe malnutrition, unwell infants, or where there are concerns about the child’s care at home.


• Infants who have had a period of failure to thrive are at risk of long-term problems with growth and development.



Definition


FTT can be defined using various criteria. The term is generally applied to infants, although on occasion it is used in children up to 2–3 years of age. Concern is often raised when an infant’s weight is below the third centile, that is, more than approximately two standard deviations below the population mean. However, this occurs normally in 3% of infants, most of whom are healthy but who are genetically destined to be small. Of more interest are the weight :length ratio, and particularly the growth trajectory with time. The criterion of weight crossing two major centile lines with time is more meaningful clinically, and a useful standard by which to decide when to describe an infant as having FTT, and to evaluate accordingly.



Growth patterns


When a child is failing to thrive, weight gain is affected first, but if the problem persists, length also may be affected. If length is affected disproportionately, the possibility of a skeletal dysplasia syndrome or endocrinopathy should be considered. Head circumference is affected only when failure to thrive is severe.


Irrespective of birth weight, full-term infants tend to assume their genetically determined growth pattern some time in mid to late infancy. This often results in babies who were born large ‘crossing down’ to reach their predestined track on the growth chart. Measures should be plotted against age corrected for prematurity until 2 years of age.


It is often possible to identify a critical point or period at which a child’s growth began to falter. This may enable recognition of an important factor that has adversely influenced growth, such as the introduction of a food to which the child is intolerant, intercurrent infection or change in environmental circumstances causing family stress.



Causes


In developed countries, failing to thrive usually relates to inadequate caloric intake in the context of psychosocial difficulties. Poverty, parental mental illness, substance abuse, social isolation, family violence or intellectual disability may result in limited parental capacity or other priorities competing with adequate care of the child. The relationship between mother and infant is often disturbed. Maternal depression is very common in these situations, often present from the postnatal period or developing as a consequence of feeding difficulties and associated FTT.


Prematurity, intrauterine growth retardation and embryopathic intrauterine exposures increase the risk of FTT. Chronic or recurrent illness in any system can result in impaired growth (Table 3.7.1).


Table 3.7.1 Organic causes of failure to thrive

































































System Examples
Craniofacial Cleft palate
Pierre Robin syndrome
Neurological Cerebral palsy with pseudobulbar palsy
Raised intracranial pressure (vomiting)
Embryopathy (e.g. in utero infection, fetal alcohol syndrome)
Genetic Chromosomal abnormality (e.g. trisomy 18)
Dysmorphic syndrome (e.g. Smith–Lemli–Opitz syndrome)
Gastrointestinal Gastro-oesophageal reflux disease
Malabsorption (e.g. coeliac disease, lactose intolerance)
Chronic liver disease
Renal Recurrent/persistent urinary tract infection
Chronic renal failure
Renal tubular acidosis
Respiratory Chronic lung disease (e.g. bronchopulmonary dysplasia, cystic fibrosis)
Chronic upper airway obstruction
Metabolic Inborn errors of metabolism (e.g. amino acidopathies, mitochondrial disorders)
Cardiac Chronic congestive cardiac failure
Endocrine Thyroid disease
Adrenal insufficiency
Immunological Severe atopic disease
Food protein allergy
Severe combined immune deficiency
Infectious Human immunodeficiency virus
Tuberculosis

Mechanisms of growth failure include reduced intake (most common), inadequate nutrient absorption and, in some cases, increased energy utilization. Malnourished infants are vulnerable to infection, which may further compromise their nutritional state.


In some cases, parents hold alternative belief systems that influence their care of their child. These may include unconventional diets and feeding practices, opposition to immunization and mistrust of mainstream health-care providers. These cases can be extremely challenging and great skill is required to maintain a therapeutic relationship with the family.


There are often multiple contributing causes for failing to thrive. For example, an infant may have an underlying syndromic diagnosis that is associated with growth restriction but also results in recurrent infections, gastro-oesophageal reflux and irritability with poor feeding behaviour. Psychosocial problems may also be present in the family of a child with organic illness.

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Aug 4, 2016 | Posted by in PEDIATRICS | Comments Off on Failure to thrive

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